A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?

Beefy, red tongue

Paroxysmal cough

Peeling of the hands and feet

Fever

Answer and Explanation

The Correct Answer is D

A) Beefy, red tongue: The beefy, red tongue is typically associated with scarlet fever, a bacterial infection caused by group A Streptococcus. This condition can lead to a red, "strawberry" tongue, often accompanied by a rash. While measles can involve a variety of symptoms, including a red rash, conjunctivitis, and cough, the beefy red tongue is not characteristic of measles. In measles, the more notable symptoms are a high fever, cough, runny nose, and the development of Koplik spots inside the mouth.

B) Paroxysmal cough: Paroxysmal cough, which is a sudden, severe, and uncontrollable cough often followed by a "whooping" sound, is more characteristic of pertussis (whooping cough). While a cough is indeed present with measles, it is generally not paroxysmal. In measles, the cough is more persistent and associated with other typical symptoms such as fever and a characteristic rash. The coughing in measles may also be dry and harsh but does not tend to occur in violent, paroxysmal episodes like those seen in pertussis.

C) Peeling of the hands and feet: Peeling of the skin, particularly of the hands and feet, is more commonly observed in conditions such as scarlet fever, Kawasaki disease, or after a viral infection like hand-foot-and-mouth disease. It is not a classic finding of measles. In measles, the skin rash usually starts as maculopapular spots on the face and spreads down the body. While some skin sloughing can occur after the rash resolves, especially in severe cases, it is not the characteristic sign of measles, and it is not typically seen on the hands and feet.

D) Fever: Fever is one of the earliest and most prominent symptoms of measles. It typically appears about 2-4 days before the characteristic measles rash. The fever in measles can be quite high, often exceeding 104°F (40°C), and is associated with other symptoms such as cough, conjunctivitis, and photophobia. The fever usually persists for several days, and it is one of the critical signs that lead to the diagnosis of measles, particularly when combined with the characteristic rash and other respiratory symptoms.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

B. A chest X-ray: The client’s symptoms (cough, blood-tinged sputum, night sweats, fever, and weight loss) are concerning for tuberculosis (TB) or another pulmonary infection. A chest X-ray is a key diagnostic tool to assess for lung abnormalities, including TB infiltrates or cavitations.

D. A Mantoux test: The Mantoux tuberculin skin test (TST) is used to screen for Mycobacterium tuberculosis infection. Given the client’s recent travel to South Africa, a high TB prevalence area, and their symptoms, TB testing is crucial.

Incorrect:

A. A pulmonary function test: This evaluates chronic respiratory conditions like asthma or COPD, but is not a first-line test for an acute cough with systemic symptoms.

C. A nasopharyngeal swab: This is used for diagnosing viral infections like influenza or COVID-19, which are less likely given the client’s blood-tinged sputum and prolonged systemic symptoms.

E. Blood cultures: These are used to detect bacteremia or sepsis, but there is no indication of systemic bacterial infection (e.g., hemodynamic instability, severe leukocytosis).

A. Prolonged PT/INR B. Elevated lipase C. Decreased albumin D. Elevated ammonia

Correct Answer is B

Explanation

A) Prolonged PT/INR:
A prolonged PT/INR is typically associated with liver dysfunction or clotting disorders. While pancreatitis can lead to complications like bleeding, it does not directly cause a prolonged PT/INR. In the case of pancreatitis, the main concerns are related to enzymes, fluid and electrolyte imbalances, and potential organ dysfunction, but clotting issues are not a primary diagnostic feature.

B) Elevated lipase:
This is the most characteristic lab finding in pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly when the pancreas is inflamed. Elevated lipase levels are a key diagnostic indicator of pancreatitis, often seen alongside elevated amylase levels. This finding helps confirm the diagnosis and monitor the severity of the condition.

C) Decreased albumin:
Decreased albumin levels are typically seen in conditions that affect liver function, kidney disease, or malnutrition. While pancreatitis can lead to some degree of malnutrition or fluid shifts, a decreased albumin level is not a specific or expected finding in pancreatitis itself. The focus is more on enzyme levels and possible complications like hypocalcemia or hyperglycemia.

D) Elevated ammonia:
Elevated ammonia levels are generally indicative of liver dysfunction or hepatic encephalopathy, which occurs in severe liver disease. While pancreatitis can cause systemic complications, an elevated ammonia level is not a typical lab finding associated with pancreatitis. Ammonia is more commonly monitored in cases of liver failure or cirrhosis.

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A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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Explanation

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